CONTENDING WITH UNCERTAINTY: IMPLEMENTING THE CMS ACUTE HOSPITAL CARE AT HOME WAIVER PROGRAM IN THE UNITED STATES

Abstract As Congress considers renewing the Acute Hospital Care At Home (AHCaH) waiver, which provides a full hospital payment for Hospital at Home (HaH) care, evaluating uncertainty around the future of HaH payment is critical. Our qualitative study explored HaH leaders’ experiences with implementing HaH (N=18, clinical/medical directors, operational and program managers) from 14 new and pre-existing programs across the U.S. We conducted semi-structured interviews with HaH programs diverse by size, urbanicity, and geography. We analyzed transcripts using a thematic approach. Participants across settings and regions wanted greater clarity about the waiver’s future. Lack of clarity affected staffing (nurses reluctant to take temporary jobs) and investment in establishing programs (building EMR components, changing workflows, creating inpatient processes in an outpatient setting). Programs adapted to uncertainty in multiple ways: 1) operating parallel waiver and non-waiver programs; 2) seeking to determine/ calculate the HaH value for their institution; 3) determining which patients would benefit most from HaH; and 4) seeking additional health system financing options beyond the CMS reimbursement (new programs) or relying on existing contracts with payers (existing programs). Implementing HaH is a complex and resource intensive process. Greater clarity from CMS regarding the waiver’s future state will encourage programs to invest the resources that they need to establish their programs long-term. Waiver extension/ permanence would also enable programs to develop and test measures of value, making rigorous evaluations possible to optimize different HaH components.

based on the benefit of the drug for a specific problem. For research purposes the definition is more commonly conceptualized as being equivalent to taking five or more medicines. Polypharmacy is noted to be presented in about 40% of older adults living in the community. Limited research has focused specifically on polypharmacy in assisted living settings. In addition to concerns about polypharmacy in assisted living there has also been a focus on the use of psychotropic medication and opioids in these settings as prevalence ranges from 53% to 68%. Although there are not regulations related to decreasing polypharmacy via deprescribing or to decrease use of psychotropics or opioids in assisted living, there are currently major initiatives in geriatrics to focus on these areas. This symposium will provide current data on medication use and polypharmacy among a large sample of 781 assisted living residents from 85 communities across three states and address the impact of a Function Focused Care approach on decreasing polypharmacy and use of psychotropics and opioids. Lastly data will be provided on the value of Deprescribing Networks to help decrease polypharmacy within these settings. The findings from this symposium will provide recommendations for future research as well as guidance for clinical practice.

THE IMPACT OF FFC-AC-EIT ON DECREASING USE OF PSYCHOTROPIC MEDICATIONS AND OPIOIDS IN ASSISTED LIVING Barbara Resnick, University of Maryland, Baltimore, Maryland, United States
The secondary aim of the study testing the impact of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) was to decrease psychotropic medications and opioids among assisted living residents. Function Focused Care is a philosophy of care in which direct care workers are taught how to evaluate older adults' underlying function and physical activity and optimize their participation in all activities. This randomized controlled trial included 85 communities and 781 residents across three states. A total of 501 out of 794 participants (63%) received at least one psychotropic medication or opioid. Except for opioid use at four months, there was no significant difference in the intervention groups with regard to medication use at any time point. The findings suggest that encouraging participation in physical activity during all care interactions does not result in an increase in the need for and prescribing of psychotropic medications or opioids.

POLYPHARMACY IN ASSISTED LIVING
Elizabeth Galik, University of Maryland, Baltimore, Baltimore, Maryland, United States The purpose of this study was to describe polypharmacy in assisted living settings, evaluate the factors that influence polypharmacy and the impact of polypharmacy on clinical outcomes. Baseline data from the study entitled, Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) was used. Total number of drugs taken daily among the 781 participants was 5.16 (SD=2.40) and over half (N=484, 62%) were exposed to polypharmacy. None of the predicted variables (age, gender, race, setting, diagnoses, and cognition) were associated with polypharmacy (Wald = .207, p=.65). Similarly, controlling for age, gender, race, setting, diagnoses, cognition, function, and physical activity, polypharmacy was not associated with falls, emergency room visits or hospitalizations. Factors not included in the data contributing to the high rate of polypharmacy in assisted living settings will be discussed and recommendations for further research and practice implications reviewed. Deprescribing is defined as the thoughtful process of "tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving outcomes." There are multiple clinical issues that deprescribing can address such as: antibiotic resistance caused by inappropriate and excessive use, the ongoing opioid epidemic, as well as over treatment particularly at the end of life. Networks have been established to address deprescribing across settings including assisted living nationally and internationally. Fourteen key informants from these networks were interviewed including different disciplines. From the interviews, six major themes across two domains were identified. The two domains included regional resources and knowledge gaps and the six themes included: (a) network structure, (b) public perception, (c) policy implications, (d) implementation, (e) challenges, and (f) recommendations. Overall, the importance of collaboration among interprofessional team members will be critical to the success of deprescribing as this clinical issue moves ahead. As Congress considers renewing the Acute Hospital Care At Home (AHCaH) waiver, which provides a full hospital payment for Hospital at Home (HaH) care, evaluating uncertainty around the future of HaH payment is critical. Our qualitative study explored HaH leaders' experiences with implementing HaH (N=18, clinical/medical directors, operational and program managers) from 14 new and pre-existing programs across the U.S. We conducted semi-structured interviews with HaH programs diverse by size, urbanicity, and geography. We analyzed transcripts using a thematic approach. Participants across settings and regions wanted greater clarity about the waiver's future. Lack of clarity affected staffing (nurses reluctant to take temporary jobs) and investment in establishing programs (building EMR components, changing workflows, creating inpatient processes in an outpatient setting). Programs adapted to uncertainty in multiple ways: 1) operating parallel waiver and non-waiver programs; 2) seeking to determine/ calculate the HaH value for their institution; 3) determining which patients would benefit most from HaH; and 4) seeking additional health system financing options beyond the CMS reimbursement (new programs) or relying on existing contracts with payers (existing programs). Implementing HaH is a complex and resource intensive process. Greater clarity from CMS regarding the waiver's future state will encourage programs to invest the resources that they need to establish their programs long-term. Waiver extension/ permanence would also enable programs to develop and test measures of value, making rigorous evaluations possible to optimize different HaH components. In April 2021, New York's "Safe Staffing" law capped Long-Term Care Facility (LTCF) profits. LTCFs with "excess profits" are now challenging the law in court. This study examined how LTCFs involved in the lawsuit differed from other NY state LTCFs before and during the COVID-19 pandemic. LTCF "Safe Staffing" lawsuit data were obtained from Long Term Care Community Coalition, then linked with Centers for Medicare and Medicaid Services COVID-19 and Small Business Association Paycheck Protection Program (PPP) data. First, we tested for differences across quality measures. We found that, compared to LTCFs not involved in the lawsuit, LTCFs in the lawsuit were more likely to be located outside of a hospital, report more certified beds and higher occupancy rates, and have higher overall quality scores. LTCFs in the lawsuit also reported lower staff ratings and staffing hours, which have previously been identified as a determinant of higher mortality in LTCFs. To create valid comparisons given these systematic differences, we specified "Doubly Robust" Augmented Inverse Probability Weighted regression models and tested if lawsuit involvement was associated with COVID-19 outcomes. Despite finding higher rates of admitting patients infected with COVID-19 in "excess profit" LTCFs, we did not find that COVID-19 deaths differed by lawsuit involvement. Finally, lawsuit involvement was associated with a higher probability of receiving a PPP loan. Before and during the pandemic, LTCFs with "excess profits" appeared fundamentally different than other NY LTCFs. How these differences impact the health of older adults receiving long-term care beyond the pandemic remains unknown.

FACTORS ASSOCIATED WITH THE AVAILABILITY OF SPECIALIZED RESOURCES TO TACKLE OBESITY IN HIGH MEDICAID NURSING HOMES
Gregory Orewa 1 , Ganisher Davlyatov 2 , Rohit Pradhan 3 , Justin Lord 4 , and Robert Weech-Maldonado 1 , 1. University of Alabama at Birmingham, Birmingham, Alabama, United States, 2. University of Oklahoma, Oklahoma City, Oklahoma,United States,3. West Liberty University,West Liberty,West Virginia,United States,4. Louisiana State University at Shreveport,Bossier City,Louisiana,United States The purpose of this research is to explore the factors associated with the availability of specialized resources required to care for obese residents in high Medicaid nursing homes (NHs) (85% or higher). Due to the vagaries of payment models---Medicaid payments lag other modes of NH reimbursements-high Medicaid NHs typically report poorer quality and financial performance. Operating in a financial perilous environment, and with obesity among the elderly on the rise, high Medicaid NH may particularly struggle to obtain the appropriate resources essential to cater to obese residents' needs. Utilizing the resource-dependent theory, we hypothesized that occupancy rate, acuity index, and payer mix may be positively associated with the availability of obesity related specialized equipment in high Medicaid NHs. The study was conducted by merging survey and secondary data sources for the year 2017-2018. Obesity related data was collected via mail surveys sent to Directors of Nursing in high Medicaid NHs, The survey data was merged with the following secondary data sources: Brown University's LTC Focus, Area Health Resource File, and the Medicare cost reports. The dependent variable was the summative obesity score that ranged from 0-19 with the larger number indicating greater availability of obesityrelated equipment/services. An ordinary least square regression with propensity score weights (to adjust for potential non-response bias), and appropriate organizational/market level control variables were used for our analysis. Results suggest that payer mix (>Medicare residents) and acuity index were positively associated with the summative obesity score (p < 0.05). Policy and managerial implications are discussed.

INFORMATION SHARING TO SUPPORT CARE TRANSITIONS FOR PATIENTS WITH COMPLEX MENTAL AND BEHAVIORAL HEALTH NEEDS Taylor Bucy, and Dori Cross, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States
Information sharing practices between hospitals and skilled nursing facilities (SNFs) are insufficient to effectively support patient handoffs. Information needs are even greater for SNFs that admit patients with complex behavioral needs. It is unclear whether these needs have prompted hospital investment in enhanced information sharing with these SNFs, and what strategies these facilities are using to meet informational needs. We use data from a 2019 nationally representative SNF survey (N=265, response rate 53%) designed to gather information on information sharing practices with hospital partners. 122 SNFs (57% of respondents) report accepting at least two of the following complex conditions: serious mental illness, substance use disorder, or medication assisted treatment. Using logistic regression models that adjust for facility ownership and rurality, SNFs that accept complex patients are significantly more likely to receive information on behavioral, mental, and functional status compared to facilities who accept none or only one type of complex patient (odds ratio=2.42; p=0.023). Unadjusted models indicate that facilities that accept complex patients lag in IT-facilitated access to hospital information, and report more difficulty securing timely access to information. The significance of these findings do not persist after adjustment, suggesting structural differences in the types of SNFs